Asymptomatic gallstone disease: Re-evaluating the threshold for surgical options in the era of precision medicine

Incidental asymptomatic gallstone disease (AGD) is prevalent, but its management remains contentious. Old-fashioned conservative care is under scrutiny today with precision medicine and artificial intelligence (AI) on the horizon. Unlike previous overviews, this review primarily focuses on clinical outcomes, surgical decision-making, and the integration of genomics, predictive analytics, and precision tools into AGD management. We emphasise how AI-based models and precision diagnostics enable tailored recommendations, preventing unnecessary cholecystectomy in low-risk patients while requiring early elective surgery in high-risk subgroups (<i>e.g.</i>, single large stones, polyps, endemic cancer areas). We also compare cost-effectiveness, surgical safety, and quality of life (QoL) measures within this precision strategy. Our vision is to overcome the binary "operate or observe" model by leveraging technology-enabled forecasting and collaborative decision-making to deliver future-proof care for AGD. The terminology of asymptomatic gallstones was used more meticulously in the era of open cholecystectomy, when neither the diagnostic tools nor the concept of minimal access surgery were available. After careful consideration of the evidence on natural history, risk of surgery, QoL, and cost, we recommend that clinicians utilise shared decision-making and present information regarding cholecystectomy as an intervention option to all patients with asymptomatic gallstones.